Fighting the worst urban overdose epidemic in the country, Philadelphia health officials have scrambled to offer more of what is proven most effective in helping opioid users reach recovery: medication-assisted treatment (MAT).

But nearly a quarter of the inpatient and outpatient treatment slots that fit the description are still empty, city officials said Thursday. That’s in a city where an estimated 70,000 people are injecting heroin.

Advocates say there’s no way to compel people to seek treatment until they are ready. Many users say fear of the pain of withdrawal keeps them from treatment, but MAT has been shown to address that problem well -- if administered quickly.

One big reason not all treatment is medication assisted: the enduring stigma against using medicine, even from drug users, many of whom still believe MAT simply exchanges one drug for another.

Other issues that keep people in addiction, advocates say, include long waits for clinical assessments that can send a drug user into withdrawal, and the time-consuming rigors of treatment itself.

“There’s multiple barriers, and for each individual there will be an eclectic mix of them,” said Brooke Feldman, an activist from Mayfair with a master’s degree in social work.

“Stigma [of MAT] is still a huge barrier. And a methadone maintenance program is like having a part-time job: You have to be at the clinic early in the morning, within a certain time slot, and that means having access to transportation, child care — and people are often traveling out of their own neighborhoods."

Still, the city plans to require that all 80 city-funded inpatient treatment facilities offer MAT by next year. Even then, patients will be able to choose MAT or abstinence-based treatment.

Years of research show that MAT gives patients a better shot at recovery. A 2015 study that followed people addicted to prescription painkillers and treated with Suboxone (an MAT drug that combines buprenorphine and the overdose-reversing drug naloxone), found that 61 percent of patients were still in recovery three years later.

Another study, comparing patients who took the opioid blocker naltrexone with patients who opted for traditional abstinence-based treatment, found that relapse rates within one month were significantly higher among people who opted for a traditional short-term abstinence-based inpatient stay.

There always will need to be some slots left open so that people in addiction can get treatment as soon as they are ready for it. That’s essential, because withdrawal is so painful, many users will return to drug use if they can’t get care. And there always will be a need for abstinence-based treatment. MAT isn’t appropriate for people who need treatment for addiction to cocaine or methamphetamine.

But just as diabetes and cancer patients often have options, so should those whose disease is a substance-use disorder, advocates say.

“We believe that choice is essential. You should be an active decision-maker in making health-care decisions,” said David T. Jones, the commissioner of the city’s Department of Behavioral Health and Intellectual disAbility Services. “Part of what we believe is that, based on the evidence and science, it’s absolutely clear that for people with an opioid use disorder, MAT is the best course for the recovery process.”

MAT combines either an opioid-replacement drug like methadone or buprenorphine, or an opioid blocker like naltrexone, with therapy. In 2017, 75 percent of Medicaid recipients being treated for an opioid use disorder in Philadelphia were getting some form of MAT. (Of the 32,000 Philadelphians getting treatment for substance-use disorder, through the low-income public insurance, about 15,000 have an opioid use disorder.)

The city said it added 3,000 more MAT slots in 2018, for a total of 12,479 MAT-capable slots. That figure includes beds at inpatient treatment facilities, outpatient treatment programs, and private doctors authorized to prescribe buprenorphine and naltrexone. Yet 2,900 of those slots are still open, Jones said. The city is also launching a media campaign to encourage more people to get MAT.

(A recently released Pew Charitable Trusts report found that as of September, just under half of the slots at the city’s state-licensed treatment centers could offer MAT. Though the report acknowledged that state-licensed treatment centers don’t reflect the city’s total MAT capacity, city officials disapproved of its framing.)

Advocates for people in addiction say that the mere availability of slots isn’t enough to persuade some people to get MAT.

Feldman, who has been in recovery for 14 years, said that when she first entered treatment for an opioid addiction in 2005, she wasn’t offered MAT. But she isn’t sure she would have taken it even if it had been available at the time.

“Through what I heard in my treatment and recovery experience, it was, ‘You’re taking the easy way out’ and ‘If I can overcome an opioid use disorder without medication, you can,’ ” she said.

Carol Rostucher, a recovery specialist who runs the Kensington advocacy group Angels in Motion, said many of her clients “don’t want to be stigmatized anymore.” Others balk at the time requirements of intensive outpatient programs that require therapy sessions in addition to MAT. Some live in recovery houses that will bar anyone on MAT.

And many people who have had success on MAT are afraid to reveal it, Rostucher said.

“I’ve worked with individuals who felt ashamed of their use of medication and felt like they needed to hide in groups like Narcotics Anonymous,” Feldman said. “I’ve met people in the behavioral health field who felt the need to hide their use of medications because they felt like they would be stigmatized by colleagues.”

Jennifer Smith, the secretary of the state Department of Drug and Alcohol Programs, said the state is working to expand MAT access as well. Some health insurance companies are updating contracts to require that their own treatment providers offer MAT.

“We try to take every opportunity that we have to frame it as just another medication, no different from other health-related medications,” Smith said. She pointed to her father, who has diabetes, as an example: For years he controlled his condition through his diet, then with pills, and now has to take insulin twice a day.

“Addiction and MAT is really no different from that. Some people manage to get to recovery without medication,” she said. “There are others who need less intense medication, or maybe only need it for a short period of time. And then you have individuals who really, on a long-term basis, simply need that medication in order to combat the disease."